Perspectives on Safety

Our Perspectives on Safety section features expert viewpoints on current themes in patient safety, including interviews and written essays published monthly. Annual Perspectives highlight vital and emerging patient safety topics.

Interview

Dr. Haas is an obstetrician–gynecologist and co-Principal Investigator for Ariadne Labs' work focused on health care system expansion. We spoke with her about the trend of health systems getting larger and more integrated, the risks to patient safety, and ways to mitigate these risks.

Annual Perspective

Patient engagement is widely acknowledged as a cornerstone of patient safety. Research in 2018 demonstrates that patient engagement, when done correctly, can help health care systems identify safety hazards, regain trust after they occur, and codesign sustainable solutions.

Interview

Dr. Krumholz is Professor of Medicine at the University of Yale School of Medicine and Director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation. We spoke with him about readmissions and post-hospital syndrome, a term he coined in an article in the New England Journal of Medicine to describe the risk of adverse health events in recently hospitalized patients.

Interview

Dr. Aiken is Claire M. Fagin Leadership Professor of Nursing, Professor of Sociology, and Director of the Center for Health Outcomes and Policy Research at University of Pennsylvania. She is generally considered the nation's foremost expert on health policy as it relates to the nursing workforce. We spoke with her about how nurse staffing and the work environment can affect patient safety and outcomes.

Interview

Dr. Starke is Professor of Pediatrics–Infectious Disease at Baylor College of Medicine and previously served as Infection Control Officer at Texas Children's Hospital. We spoke with him about "presenteeism" (coming to work while ill) in health care and its impact on provider and patient safety.

Interview

Dr. Dixon-Woods is RAND Professor of Health Services Research at Cambridge University, Deputy Editor-in-Chief of BMJ Quality and Safety, and one of the world's leading experts on the sociology of health care. We spoke with her about new ways to approach safety culture.

Annual Perspective

The toll of medical errors is often expressed in terms of mortality attributable to patient safety problems. In 2016, there was considerable debate regarding the number of patients who die due to medical errors. This Annual Perspective explores the methodological approaches to estimating mortality attributable to preventable adverse events and discusses the benefits and limitations of existing approaches.

Interview

Mr. O'Neill served as the United States Secretary of the Treasury under President George W. Bush and, prior to that, chairman and CEO of Alcoa. We spoke with him about workplace safety and its relationship to patient safety and organizational excellence.

Perspective

This piece explores how a team at Beth Israel Deaconess Medical Center combined tools and techniques used in manufacturing along with continuous improvement to develop a process to identify, prioritize, and mitigate hazards in health care settings.

Annual Perspective

Opioids are known to be high risk medications, and concerns about patient harm from prescription opioid misuse have been increasing in the United States. This Annual Perspective summarizes research published in 2016 that explored the extent of harm from their use, described problematic prescribing practices that likely contribute to adverse events, and demonstrated some promising practices to foster safer opioid use.

Interview

Dr. Bagian is Director of the Center for Healthcare Engineering and Patient Safety at the University of Michigan, and a former astronaut. He co-chaired the team that produced the influential NPSF report entitled, RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.

Interview

Dr. Bindman, an expert in health policy in underserved populations, was appointed as director of the Agency for Healthcare Research and Quality (AHRQ) in May 2016. We spoke with him about his new role at AHRQ.

Interview

Dr. Meyer is Chief Clinical Officer of Partners Healthcare System, the large Boston-based system that includes Massachusetts General and Brigham and Women's Hospitals. We spoke with him about training and certification in patient safety.

Annual Perspective

Computerized provider order entry is a cornerstone of patient safety efforts, and the increasingly widespread implementation of electronic health records has made it a standard practice in health care. This Annual Perspective summarizes novel findings and research directions in computerized provider order entry in 2015.

Interview

Ten years of AHRQ Patient Safety Network: A Window Into the Evolution of the Patient Safety Literature, November 2015

Dr. Shojania is Editor-in-Chief of BMJ Quality and Safety and Director of the Centre for Quality Improvement and Patient Safety at the University of Toronto. We spoke with him about the evolution of patient safety research over the past 15 years.

Interview

Ten years of AHRQ Patient Safety Network: A Window Into the Evolution of the Patient Safety Literature, November 2015

Ms. Zipperer was a founding staff member of the National Patient Safety Foundation as their information projects manager and has also been Cybrarian for AHRQ Patient Safety Network since its inception. We spoke with her about the role of librarians in patient safety.

Interview

Dr. Wachter is Professor and the Interim Chairman of the Department of Medicine at UCSF. We talked with him about his new book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age.

Interview

Dr. Birkmeyer is Chief Academic Officer and Executive Vice President at Dartmouth-Hitchcock Medical Center. We spoke with him about his seminal New England Journal of Medicine video study that found a link between practicing surgeons' directly observed technical skills and surgical outcomes.

Interview

A pioneer in patient safety, Dr. Leape is Adjunct Professor of Health Policy at the Harvard School of Public Health and Chairman of the Lucian Leape Institute of the National Patient Safety Foundation. His groundbreaking research has focused on patient safety and quality of care. We spoke with him about checklists and the field of patient safety.

Interview

Dr. Urbach is Professor of Surgery and Health Policy, Management and Evaluation at the University of Toronto. We spoke with him about his study evaluating the effectiveness of checklists in Ontario, Canada and its implications for a variety of safety interventions.

Interview

Sir Brian Jarman designed the methodology for hospital standardized mortality ratios, a widely used method of measuring quality and safety, and was involved with the Bristol Royal Infirmary Inquiry. We spoke with him about the development of the HSMR and their role in monitoring performance.

Perspective

with commentary by Ian Scott, MBBS, MHA, MEd, Risk-Adjusted Mortality as a Safety/Quality Measure, March 2015

This piece discusses risk-adjusted hospital mortality rates as a measure of hospital safety, including why they've become popular, major flaws such as low sensitivity, and alternative ways to use them.

Interview

Dr. Kelley, PhD, is Director of Service Delivery and Safety for the World Health Organization (WHO). We spoke with him about his work with WHO and the global impact of the organization on patient safety.

Interview

Ms. Gibson is Senior Advisor to The Hastings Center, an editor for JAMA Internal Medicine, and co-author of Wall of Silence and The Treatment Trap. We spoke with her about overuse of medical care and its effect on patient safety.

Interview

Dr. Sarkar is an associate professor of medicine at UCSF whose research has focused on ambulatory patient safety, including missed and delayed diagnosis, adverse drug events, and monitoring failures for outpatients with chronic diseases. We spoke with her about patient safety in the ambulatory setting.

Interview

Dr. Gandhi is President of the National Patient Safety Foundation and Associate Professor of Medicine at Harvard Medical School. We spoke with her about NPSF's evolving role in enhancing health care at a national level.

Interview

Dr. Coiera, a professor at the University of New South Wales, has extensively researched and written about clinical communication processes and information systems. We spoke with him about how interruptions and distractions in the clinical environment influence patient safety.

Interview

Prof. Needleman has performed some of the key studies on how the nursing workforce influences health outcomes, including seminal articles published in the New England Journal of Medicine in 2002 and 2011.

Interview

Disclosing Errors and Other Innovations in Risk Management, March 2012

An attorney and chief risk officer for the University of Michigan Health System, Mr. Boothman developed a pioneering approach to medical mistakes and risk management, emphasizing an honest approach to errors, early apology, and rapid settlement offers when the system was at fault.